Fillable Printable Post Sports-Related Head Injury Medical Clearance and Authorization Form - Massachusetts

Post Sports-Related Head Injury Medical Clearance and Authorization Form - Massachusetts

The student must be completely symptom free at rest, during exertion, and with cognitive activity prior to

returning to full participation in extracurricular athletic activities. Do not complete this form until a graduated

return to play plan has been completed and the student is found to be symptom free at rest, during exertion

and with cognitive activity.

Student’s Name Sex Date of Birth Grade

Date of injury: _________________ Nature and extent of injury: _____________________________________

Symptoms following injury (check all that apply):

□ Nausea or vomiting □ Headaches □ Light/noise sensitivity

□ Dizziness/balance problems □ Double/blurry vision □ Fatigue

□ Feeling sluggish/”in a fog” □ Change in sleep patterns □ Memory problems

□ Difficulty concentrating □ Irritability/emotional ups and downs □ Sad or withdrawn

□ Other

Duration of Symptom(s): _____________ Diagnosis: □ Concussion □ Other: __________________________

If concussion diagnosed, date student completed graduated return to play plan without recurrent symptoms: ________

Prior concussions (number, approximate dates): ________________________________________________________

I HEREBY AU THORIZE THE ABOVE NAMED STUDENT FOR RETURN TO EXTRACURRICULAR ATHLETIC

ACTIVITY

Practitioner signature: _______________________________________ Date: _______________

Print Name:______________________________________________________

□ Physician □ Licensed Athletic Trainer □ Nurse Practitioner □ Neuropsychologist □ Physician Assistant

License Number: _______________

Address: ____________________________________ Phone number: ___________________

Name of Physician providing consultation/coordination/supervision (if not person completing this form; please

print): ____________________________________________________

I ATTEST THAT I HAVE RECEIVED CLINICAL TRAINING IN POST-TRAUMATIC HEAD INJURY ASSESSMENT

AND MANAGEMENT APPROVED BY THE DEPARTMENT OF PUBLIC HEALTH* OR HAVE RECEIVED

EQUIVALENT TRAINING AS PART OF MY LICENSURE OR CONTINUING EDUCATION.

Practitioner’s initials: _______

Type of Training:

 CDC on-line clinician training Other MDPH approved Clinical Training  Other

(Describe)_________________________________________________

* MDPH approved Clinical Training options can be found at: www.mass.gov/dph/sports concussion

This form is not complete without the practitioner’s verification of such training.

The Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Public Health

POST SPORTS-RELATED HEAD INJURY

MEDICAL CLEARANCE AND

AUTHORIZATION FORM